Cme/Ceu Checklist


Date of Activity:

Name of Activity:

UNITS: CME: ______CE: ______

Application Fee: $______
Administrative Fee: $______
Section A: Joint Provider Information
Section B: Joint Provider Agreement
Section C: Activity Information
·  Needs Assessment
·  Course Learning Objectives
·  Desirable Physician Attributes (i.e. IOM competencies, ACGME competencies)
·  Evaluation Form
·  Target Audience
·  Event Format
·  Cultural & Linguistic Competency
Individual Session (s) Information
Brochure/Flyer Marketing Materials
Intended Audience
PAC/LAC listed as joint Provider of event
Learning Objectives
Name and credentials of program faculty
Agenda (inc. list time, topic, faculty for each slot)
Cost (if event is free, the flyer must state so)
Materials supplied (e.g. course syllabus, breakfast, lunch)
Cancellation and refund policy
Notification of any “Commercial Support” (e.g. Funded by APEX industries)
Appropriate CME/CEU language
Section D: Planning Committee
Section E: Faculty
Section F: Financial & Commercial Support
Proposed Budget
Letters of Agreement for Financial Support
Certificates Sent:

MATERIALS REQUIRED AFTER CME ACTIVITYmust be submitted within 1 month after event

Sheet
Evaluation Summary
Analysis of changes in MD competence, performance or patient outcomes
Final Budget (revenue and expenses)
Tally of attendees (i.e. total physicians, total RN’s, total others)
List of attendees who received credit
Course Syllabus and/or any hard copy materials disseminated
Verification of Disclosure Form
Date / Notes

Rev. 9/2014